Minimum Standards for Child and Adolescent HIV, TB and Malaria Continuum of care and Support in the SADC Region ( )

Transcription

1 TOWARDS A COMM ON FUTURE USOUTHERN AFRICAN DEVELOPMENT COMM NITY Approved November 2013 Minimum Standards for Child and Adolescent HIV, TB and Malaria Continuum of care and Support in the SADC Region ( )

2 ORIGINAL IN ENGLISH

3 ACKNOWLEDGEMENTS ISBN: The contents for this publication are the sole responsibility of SADC. The designations employed in the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the SADC Secretariat concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitations of its frontiers or boundaries. The mention of specific companies, organizations, or certain manufacturers products does not imply that they are endorsed or recommended by the SADC Secretariat in preference to others of a similar nature that are not mentioned. For more Information Directorate of Social and Human Development And Special Programs SADC Secretariat Private Bag 0095 Gaborone, Botswana Tel (267) Fax (267) registry@sadc.int Website:

4 2 Minimum Standards for Child and Adolescent HIV, TB and Malaria TABLE OF CONTENTS ACKNOWLEDGEMENTS 1 ACRONYMS AND ABBREVIATIONS 3 KEY DEFINITIONS 4 1. Background Overview of paediatric HIV and AIDS, TB and malaria in the SADC region Foundation for developing Minimum Standards in the SADC region Rationale for the Minimum Standards 7 2. PROCESS FOR DEVELOPING THE MINIMUM STANDARDS 7 3. CONCEPTUAL FRAMEWORK FOR THE MINIMUM STANDARDS: THE CONTINUUM OF CARE AND SUPPORT APPROACH 8 4. PURPOSE AND SCOPE 9 5. EXPECTED OUTCOMES 9 6. GUIDING PRINCIPLES MINIMUM STANDARDS FOR CHILD AND ADOLESCENT HIV AND AIDS, TB AND MALARIA CONTINUUM OF CARE Standards for HIV and AIDS prevention, diagnosis, treatment and care in children and adolescents Standards for TB prevention, diagnosis, treatment and care in children and adolescents Standards for malaria prevention, diagnosis, treatment and care in children and adolescents Cross-cutting standards on care and support for children and adolescents Standards on health systems strengthening and integration IMPLEMENTATION PROCESS AND MECHANISMS Stakeholder roles and responsibilities Financing mechanisms Dissemination strategies Monitoring and evaluation 18 REFERENCES 20

5 Minimum Standards for Child and Adolescent HIV, TB and Malaria 3 ACRONYMS & ABBREVIATIONS ACT ACSM AIDS ART ARV BCG CHBC CoCS CPT DOTS IPT IRS ITNs LLINs MDG MDR-TB M&E MNCH MTCT NGO NNRTI NRTI PEP PHC PITC PMTCT PSS RDT SADC SAfAIDS SRHR STI TB UN UNICEF UNAIDS WHO Artemisinin combination therapy Advocacy, communication and social mobilisation Acquired immune deficiency syndrome Antiretroviral therapy Antiretroviral Bacille Calmette-Guérin Community home-based care Continuum of care and support Cotrimoxazole preventive therapy Directly observed treatment, short course Isoniazid preventive therapy Indoor residual spraying Insecticide-treated bed nets Long-lasting insecticide nets Millennium Development Goal Multidrug-resistant TB Monitoring and evaluation Maternal, neonatal and child health Mother-to-child transmission (of HIV) Nongovernmental organisation Non-nucleoside reverse transcriptase inhibitor Nucleoside reverse transcriptase inhibitor Post-exposure prophylaxis Primary health care Provider-initiated HIV testing and counselling Prevention of mother-to-child transmission Psychosocial support services Rapid diagnostic test for malaria Southern African Development Community Southern Africa HIV and AIDS Information Dissemination Service Sexual reproductive health and rights Sexually transmitted infection Tuberculosis United Nations United Nations Children s Fund The Joint United Nations Programme on HIV/AIDS World Health Organization

6 4 Minimum Standards for Child and Adolescent HIV, TB and Malaria KEY DEFINITIONS Adolescent: This document uses the WHO definition of adolescent: A person 10 to 19 years old. [1] Adolescent-friendly services: Adolescent-friendly health services are defined in this document as health services that do not discriminate or intimidate and that are accessible, acceptable, affordable and appropriate for adolescents and young people. This definition is based on the WHO Operational Guidelines on HIV Testing of Infants, Children and Adolescents for Service Providers in the African Region. [2] Caregiver: A caregiver is any person giving care to a child in the home environment. The primary caregiver is the main person who lives with a child and provides regular parenting care for the child in a home environment. This often includes family members, such as parents, foster parents, legal guardians, siblings, uncles, aunts and grandparents or close family friends. Secondary caregivers include community members and professionals (such as nurses, teachers or play centre minders) who interact with a child in the community or visit a child at home, but who do not necessarily live with the child. Child and youth caregivers include children and youth who are caring for other children, ill parents and relatives and/or heading households. Child: This document uses the child definition of the SADC Strategic Framework and Programme of Action ( ) for Comprehensive Care and Support for OVCY, taken from the UN Convention of the Rights of the Child: Every human being below the age of 18. [3] Child-friendly services: A system of care that focuses on the physical, psychological, and emotional wellbeing of children attending health care facilities. A separate waiting area should be provided for children where they are contained and safe, and are able to play and explore. Health care workers who are identified as being good with children or have been specifically trained in paediatrics should staff the clinic. Counsellors may require special training to provide ageappropriate counselling and be sensitive to non-verbal communication. Children and their parents or caregivers should feel able to ask questions. Medical procedures (for example, phlebotomy or injections) should be explained to the child to allay anxiety. [2] Comprehensive care and support: This refers to interventions or service delivery efforts that meet the complete set of basic needs or defined minimum standards across multiple services that addresses the survival, development, protection and participation rights of children and youth while addressing vulnerability. Continuum of care and support: An integrated system of care for children from pregnancy to delivery, the immediate post-natal period, and childhood through adolescence. It guides and tracks patients over time through a comprehensive array of health services spanning all levels of care: outpatient services, clinics and other health facilities, and by families and communities. [4] Harmonisation: All SADC Member States are aligned to a common minimum standard of services that holistically address HIV, TB and malaria in children and adolescents. Holistic approach: A procedure for ensuring that different options or strategies are considered and applied flexibly in appropriate combinations that ensure comprehensive or optimal fulfillment of the wellbeing and development of a child. Integration: This document uses the WHO definition of integration: The organization and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money. [5] This requires a continuum of funding, administration, organisation, service delivery and clinical strategies designed to create connectivity, alignment and collaboration of HIV, TB and malaria programmes within the platform of Primary Health Care services towards improving patient outcomes, efficiency and cost-effectiveness. [6] [7] Orphan: A child below the age of 18 years who has lost one or both parents. The concept of social orphans may be used to describe children whose parents may be alive, but who are no longer fulfilling any of their parental duties. [8]

7 Minimum Standards for Child and Adolescent HIV, TB and Malaria 5 Palliative care for children: The WHO definition is used in this document: Palliative care for children refers to the active total care of the child s body, mind and spirit, and also involves giving support to the family. It begins when illness is diagnosed, and continues regardless of whether or not a child receives treatment directed at the disease. Health providers must evaluate and alleviate a child s physical, psychological, and social distress. Effective palliative care requires a broad multidisciplinary approach that includes the family and makes use of available community resources; it can be successfully implemented even if resources are limited. It can be provided in tertiary care facilities, in community health centres and even in children s homes. [9] Paediatrics: The term as applied in this document, refers to the medical care of children. Primary Health Care: This document uses the definition from the Alma-Ata declaration of 1978: Primary Health Care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and selfdetermination. It forms an integral part both of the country s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process. [10] Psychosocial support: A continuum of care and support that addresses the social, emotional, spiritual and psychological wellbeing of a person, and that influences both the individual and the social environments in which people live. [8] [11] Task shifting: A rational redistribution of tasks among health workforce teams. Specific tasks are moved, where appropriate, from highly qualified health workers to health workers with less training and fewer qualifications in order to make more efficient use of the available human resources for health. [12] Vulnerable children: Children who are unable or have diminished capacity to meet their basic needs and realize their rights to survival, development, protection and participation as a result of their physical condition, or social, cultural, economic or political circumstances and environments, and who require external support because their immediate care and support system can no longer cope. [13][11] [14]

8 6 Minimum Standards for Child and Adolescent HIV, TB and Malaria 1. BACKGROUND The Southern Africa Development Community (SADC) envisages a common future, a future within a regional community that continues to ensure socioeconomic wellbeing, freedom, social justice and peace and security. As the region moves towards achieving this vision, it faces the continuing challenges of the HIV and tuberculosis (TB) epidemics, and of high prevalence of malaria in some countries. Children and adolescents (who represent almost 50% of the SADC region s population) are particularly vulnerable to these three diseases not only in terms of direct morbidity and mortality, but also because of orphanhood and the weakening of household economies when parents and caregivers are either infected or affected Overview of paediatric HIV and AIDS, TB and malaria in the SADC region Impressive progress in child and adolescent HIV, TB and malaria has been achieved in the SADC region. However, important challenges and gaps remain. In the HIV arena, mother-to-child transmission of HIV (MTCT) resulted in an estimated new infant infections in 2010 in the region, with the rate of MTCT across Member States ranging from 3% to 37%. [15] In 2009, it was estimated that over one million children under the age of 15 years were living with HIV in SADC Member States. [16] The mean coverage of antiretroviral therapy (ART) for children, however, was a low 34%, even though some Member States have achieved more than 85% coverage. [15] The impact of TB remains high in the SADC region. Five Member States (Democratic Republic of Congo, Mozambique, South Africa, Tanzania and Zimbabwe) are among the 22 global high-burden countries that together account for approximately 80% of all new TB cases recorded globally each year. [17] Du Cros et al estimate that between 5% and 15% of TB cases are children. [18] However, it is believed that the true extent of TB-related paediatric morbidity and mortality is underestimated, due to the difficulties in confirming diagnosis of TB in children. [19] Approximately 35 million children younger than five years of age are estimated to be at risk of contracting malaria, which is responsible for one in five childhood deaths in the region. [20] In some Member States (including Malawi, Tanzania and Zambia) more than 50% of under five-year-olds were sleeping under insecticide-treated bed nets (ITNs) in the period. [21] But on average across the SADC region s malaria-affected areas, the majority of children have limited access to malaria prevention measures, diagnosis and treatment services Foundation for developing Minimum Standards in the SADC region SADC Member States have committed themselves to improving child survival and development, and to responding to HIV and AIDS, TB and malaria. To that end, Member States have signed and ratified a number of regional and international declarations. These include: The SADC Protocol on Health, which prioritises the control of communicable diseases and calls for harmonisation of policies and strategies aimed at disease prevention and control; The 2003 Maseru Declaration on the Fight Against HIV and AIDS in the SADC Region (Point 1e: Prevention and Social mobilisation by rapidly scaling up the programmes for the Prevention of Mother-to-Child Transmission of HIV ; and Point 2b: Improving care, access to counselling and testing services, treatment and support by: strengthening family- and community-based care as well as providing support to orphans and other vulnerable children ); The 2006 UNGASS Declaration of Commitment on HIV/AIDS (Point 32: Address as a priority the vulnerabilities faced by children affected by and living with HIV ); The 2006 Abuja Call for Accelerated Action Towards Universal Access to HIV and AIDS, Tuberculosis and Malaria Services; The 2006 Maputo Declaration of the 55th Regional Committee of the WHO African Region, which declared TB an emergency in Africa; and The Millennium Development Goals (MDGs), specifically Goals 4 (Reduce child mortality) and 6 (Combat HIV/AIDS, malaria and other diseases).

9 Minimum Standards for Child and Adolescent HIV, TB and Malaria Rationale for the Minimum Standards Confronted with the ongoing challenges of child survival and development in the context of the SADC regional integration agenda, as well as the move towards harmonisation of the response to HIV and AIDS, TB and malaria outlined in the SADC Protocol on Health, the SADC Secretariat is mandated to support the Scaling Up of Child and Adolescent HIV, TB and Malaria Continuum of Care in the SADC Region. This regional effort, focusing on capacity enhancement of Member States in child and adolescent HIV, TB and malaria service provision, aims to bring Member States closer to meeting international and regional targets, and to continue to improve child survival and development beyond those targets. Pivotal to this initiative was the development of these Minimum Standards for Child and Adolescent HIV, TB and Malaria Continuum of Care and Support in the SADC Region. In order to inform the development of these Minimum Standards, a Regional Assessment of Policies and Programmatic Frameworks on Paediatric HIV, TB and Malaria in the SADC region was undertaken in 14 Member States from October 2011 to July [22] The Regional Assessment noted that delivery of HIV and AIDS, TB & malaria services for children and adolescents needed to be strengthened and tailored to child- and adolescent-specific needs in SADC Member States. In addition, it showed that the delivery of services for the three diseases was not always integrated into Primary Health Care (PHC) nor linked with the delivery of other basic services to address the needs of children and adolescents, particularly those that are vulnerable. This linkage would ensure comprehensive delivery of services necessary for their optimum development (for example, nutritional and psychosocial support and child and social protection, as outlined in the SADC Minimum Package of Services for Orphans, Vulnerable Children and Youth). Strategic planning and service delivery is typically done in a sectoral, vertical and uncoordinated manner, which does not take into consideration the links between the causes and effects of these major diseases on children, adolescents and communities. Finally, the Assessment also noted that Member States are at different levels of offering services to children and adolescents for the three diseases, and that the priorities in policies, strategies and guidelines for the delivery of services also vary between Member States. In the context of the free movement of people between Member States, this makes it difficult for citizens of SADC Member States to access standard and quality services throughout the region. SADC Ministers of Health and officials responsible for HIV and AIDS responses have recognised these challenges and directed the development of regional Minimum Standards for Child and Adolescent HIV and AIDS, TB and Malaria Continuum of Care and Support. These Minimum Standards are intended to strengthen child and adolescent-specific policies and programmatic frameworks in HIV and AIDS, TB and malaria, to guide the integration of HIV and AIDS, TB and malaria services/ programmes within PHC and with basic child care services, and to facilitate harmonisation across Member States. This integration and harmonisation effort aims at improving access to standard child and adolescent HIV and AIDS, TB and malaria services across the region. Ultimately, these Minimum Standards are aimed at assisting Member States in strengthening and scaling up efforts to achieving the MDGs, and meet other regional and international commitments, and to continue to reinforce child survival and development beyond PROCESS FOR DEVELOPING THE MINIMUM STANDARDS These Minimum Standards were developed through a participatory process, which included Member States, the SADC Secretariat, development partners and various other stakeholders. A Regional Assessment of 14 Member States was undertaken between October 2011 and July 2012 to identify the status of policies, programme implementation frameworks and capacity gaps within the child and adolescent continuum of care in HIV and AIDS, TB and malaria. The Assessment involved field interviews and a desk review of the most recent international, SADC and development partners strategic frameworks/plans and guidelines/standards on treatment and care of child and adolescent HIV, TB and malaria. The findings and recommendations were compiled into a Regional Assessment Report, which informed the development of these Minimum Standards. The draft Minimum Standards document was reviewed for technical soundness by a team of regional experts during Technical Working Group meetings held in September The document was then presented to Member States and regional partners at a Regional SADC Consensus Building and Validation Meeting in October 2012.

10 8 Minimum Standards for Child and Adolescent HIV, TB and Malaria 3. CONCEPTUAL FRAMEWORK FOR THE MINIMUM STANDARDS: THE CONTINUUM OF CARE AND SUPPORT APPROACH HIV and AIDS, TB and malaria cause vulnerabilities in children by being direct sources of morbidity and mortality, and by weakening household economies when caregivers are affected. The diseases also render children more vulnerable to other serious diseases and illnesses, such as pneumonia, diarrhea and malnutrition. Vulnerabilities created by poverty, lack of access to essential services, and other causes of illness and death, in turn, render children more vulnerable to HIV, TB and malaria. Addressing only some of these vulnerabilities and deprivations is neither adequate nor sustainable. The SADC Minimum Package of Services for Orphans, and other Vulnerable Children and Youth asserts that children and adolescents require a minimum of essential interventions and services in order to attain optimum development and become productive and responsible adults. Those essential services include: Education and vocational skills; Health, clean water and sanitation; Food security and nutrition; Child and youth protection; Psychosocial support; and Social protection. The services should be delivered comprehensively, in a holistic manner, through a continuum of interventions at different stages of children s lives, from birth to early adulthood. The diminished capacity of some households to provide basic developmental services means that orphans and other vulnerable children and adolescents often fall through the cracks of service delivery systems, even when services are available. They therefore require external support to ensure they have access to all essential services. Due to the severity and interrelated nature of the HIV and AIDS, TB and malaria epidemics, the SADC Minimum Standards for Child and Adolescent HIV, TB and Malaria adopt the comprehensive and holistic service delivery approach articulated in the SADC Minimum Package of Services for Orphans, and other Vulnerable Children and Youth. Described as a Continuum of Care and Support (CoCS), this approach promotes a collective and holistic set of cost-effective, highimpact interventions to improve child and adolescent health, including the prevention, diagnosis, treatment, care and support for these three diseases, within the broader platform of PHC. It also focuses on providing appropriate links to psychosocial support, food security and nutrition, child and adolescent protection services, such as national registration and protection for those have been abused; family and community care and support systems; and education and awareness of the diseases.

11 Minimum Standards for Child and Adolescent HIV, TB and Malaria 9 According to the SADC Minimum Package of Services for Orphans, and other Vulnerable Children and Youth, delivering comprehensive essential services and CoCS requires a shift from vertical, sector-specific and isolated service delivery to an approach that is holistic. Such an approach takes into consideration the collective contributions of different service providers, children and adolescents and communities. This can be achieved through mechanisms such as: Advocating and promoting inter-sectoral coordination and collaboration; Relevant policy, legislative and management instruments to foster coordination, collaboration and effective service delivery for children and adolescents; Establishing or strengthening and implementing effective service referral systems within and between service delivery sectors and stakeholders to ensure access to essential services for vulnerable children and adolescents; Empowering children and adolescents (consistent with their age and evolving capabilities), their caregivers and communities to seek and access services; and Establishing and implementing joint sectoral planning, budgeting, and monitoring and evaluation (M&E) activities for children and adolescents. Thus the continuum of care and support approach underlining these Minimum Standards recognises that meeting the full spectrum of a child s needs beyond the biomedical or clinical ones is key to accelerating child survival and development in the SADC region. 4. PURPOSE AND SCOPE The Minimum Standards serve as a framework to guide the regional harmonisation of approaches for a continuum of care and support in HIV and AIDS, TB and malaria for children and adolescents in the SADC region. This is necessary to improve the effectiveness of national and community efforts to accelerate child survival and achieve comprehensive developmental outcomes for children and adolescents. These evidence-based standards set out the minimum requirements for all Member States, which should be achievable by all, while not limiting the ambitions and continued progress of those Member States who are ahead of these requirements. 5. EXPECTED OUTCOMES Member States will incorporate these Minimum Standards into national policies, strategic frameworks and guidelines, starting in Member States will implement and operationalise the Minimum Standards over the next five years with a mid-term review to be conducted in 2015 to ensure continued relevance of the standards and to address any challenges that hamper implementation. The implementation and operationalisation at Member State level of these Minimum Standards, through their incorporation into national policies, strategic frameworks and guidelines should result in: Harmonisation of prevention, treatment, care and support for children and adolescents affected by HIV and AIDS, TB and malaria across the SADC region; and Strengthening and scale-up of care and support of HIV and AIDS, TB, and malaria in children and adolescents as part of a broader continuum of care on maternal and neonatal-child health in all Member States. The ultimate outcome for the region is to achieve equity in the provision of health and support services to children and adolescents, thus decreasing morbidity and mortality and improving the wellbeing of children and adolescents in the SADC region, in line with global, continental and regional commitments.

12 10 Minimum Standards for Child and Adolescent HIV, TB and Malaria 6. GUIDING PRINCIPLES These Minimum Standards are based on guiding principles that define the values that should be applied and upheld by all Member States in the delivery of paediatric HIV and AIDS, TB, malaria and basic child services in the SADC region. [13] Those principles are: Child- and human rights-centred: All service providers should fulfil their obligations and act in the best interests of the child, with a view to respecting, protecting, promoting and fulfilling its rights. Interventions should promote the child s understanding of his/her rights and responsibilities from an early age. Integrated and holistic approach: Policies and programmes should aim to provide comprehensive and integrated child health services within PHC that include HIV and AIDS, TB and malaria, to ensure the wellbeing, growth and optimum development of the child and adolescent. Inter-sectoral partnerships and coordination are required, and all service providers (government, civil society, faith-based organisations and the private sector) should coordinate efforts to achieve this aim, thus ensuring appropriate referrals and complementing each other s efforts to prevent children and adolescents from falling through cracks in the system. Child and adolescent developmental perspective: Interventions should help empower and build the capacities of children and adolescents to realise their full human potential (physical, intellectual, psychological, moral, spiritual, emotional, economic and political). Services should be adapted to age-specific needs (for example, child and adolescent friendly services). Equality, non-discrimination and gender sensitivity: Policies, programmes and services should uphold nondiscrimination practices in all situations, including age, sex, gender, sexual orientation, language, religion, socioeconomic status, cultural or ethnic group and disability. Involvement and participation: Children, adolescents and their caregivers and communities should be consulted, involved and participate in the development, implementation, monitoring and accountability of policies and programmes that affect them in order to ensure relevance, appropriateness and ownership of their treatment and care. Partnerships: Institutions, organisations, civil society and services providers (including the private sector) should seek to establish working agreements and specific commitments, based on mutual respect, equality, shared responsibility and complementarity in order to contribute to and reinforce the implementation of policies and programmes for children and adolescents. Transparency: All institutions, organisations and service providers (including the private sector) should operate in an open and accountable manner. Mechanisms should be in place and should be applied to safeguard transparency and accountability at the national, regional and international levels, as well as to communities and children and adolescents who are service recipients and providers. Evidence-based: Programmes and interventions should be guided by evidence in a context-specific manner, and operational research should be used to generate more evidence of the effectiveness and cost-effectiveness of programmes. Communities and children and adolescents should be educated on the importance of evidencebased strategies so they can be empowered to advocate for them. Sustainability: Policies, programmes and services should ensure long-term benefits to children and adolescents in a continuum of care over time. To ensure long-term sustainability, the capacities of service providers, families and communities to provide care for children and adolescents should be strengthened. Children and adolescents should be empowered to advocate for their rights. They should be imbued with self-reliance and must be provided with opportunities to guarantee income generation as adults. Equity and universal access: Policies, programmes and services should aim to ensure that all children and adolescents, particularly those who are vulnerable, have the opportunity to attain their full health potential. In this regard, guaranteeing access to health services for all children and adolescents is necessary but not sufficient. Economic barriers to equity and universal access to transport, food, shelter and water should also be addressed. Do-no-harm: Programmes should ensure that interventions provide benefits and do not generate negative effects that may harm the child or adolescent, his/her family or the community.

13 Minimum Standards for Child and Adolescent HIV, TB and Malaria MINIMUM STANDARDS FOR CHILD AND ADOLESCENT HIV AND AIDS, TB AND MALARIA CONTINUUM OF CARE IThe following Minimum Standards should be clearly incorporated into national strategic frameworks/plans and clinical guidelines for treatment/management of the diseases. These Minimum Standards exist within the broader context of essential services for the child and adolescent, as outlined in the SADC Minimum Package of Services for Orphans and Other Vulnerable Children and Youth and as articulated in the conceptual framework section (see above). The standards are evidence-based and reflect international recommendations. They do not replace those international recommendations, but add value to them by rendering them appropriate to the SADC context. 7.1 Standards for HIV and AIDS prevention, diagnosis, treatment and care in children and adolescents HIV prevention HIV testing and counselling [23] Member States should strengthen efforts to ensure comprehensive knowledge of HIV and AIDS in children and adolescents; All children and adolescents presenting to a health facility should be offered routine HIV testing and counselling regardless of signs or symptoms of disease or risk factors for infection. This is referred to as provider-initiated HIV testing and counselling (PITC); HIV testing and counselling services for children and adolescents should be available at all testing sites, and steps must be taken to increase and ensure equitable access access for all children and adolescents; The principles of voluntarism, informed consent, counselling and confidentiality, correct test results and linkages to care should be observed during HIV testing and counselling [24]; Children and adolescents who are married or living together, pregnant or who are parents, who have sexually transmitted infections (STIs) or who are sexually active, as well as those who are heads of households or who have been trafficked should all be allowed to provide their own consent for HIV testing and counselling; HIV tests performed on a child or an adolescent who is under the age of consent or who is mentally incapacitated should be conducted with the consent of the parents or the legal guardian of the child or adolescent; and All HIV testing and counselling services that are provided should be in the best interest of the child or adolescent. Prevention of mother-to-child transmission Please refer to the SADC 2010 Regional Minimum Standards for PMTCT [25] and the Global Plan towards the Elimination of Mother-to-Child Transmission of HIV. [26] Prevention of sexual transmission of HIV and enhancement of adolescent sexual and reproductive health and rights Child and adolescent-friendly sexual and reproductive health services and age-appropriate information, including family planning, counselling, condoms and other contraceptives should be available at all levels of care; Child and adolescent sexual and reproductive health services should be integrated into PHC, and should be available in facilities for the treatment of STIs, as well as in HIV testing and counselling facilities, HIV and AIDS care and treatment centres, and schools and youth centres; and Positive prevention for children and adolescents living with HIV should be available. Post-exposure prophylaxis [13] Child and adolescent-friendly post-exposure prophylaxis (PEP) guidelines should be in place in all Member States; Child and adolescent-friendly PEP services should be available at all levels of health care; and PEP services should be linked to psychological and legal services. Male circumcision Adolescent medical male circumcision, with relevant informed consent, should be made available according to national guidelines.

14 12 Minimum Standards for Child and Adolescent HIV, TB and Malaria HIV diagnosis [23] [27] All children and adolescents should have access to definitive diagnostic testing for HIV; An HIV virological test should be used to determine HIV infection in infants younger than 18 months; and Early infant diagnosis should be performed in all HIV-exposed infants at 4-6 weeks after birth. HIV treatment and care Antiretroviral treatment and prevention of opportunistic infections All children under two years of age with confirmed HIV infection, irrespective of CD4 count or WHO clinical stage, should be started on ART; All children between the ages of 2 and 5 years, and who are living with HIV, should be started on ART if their CD4 count is 750 cells/mm3 or %CD4+ 25, whichever is lower, irrespective of WHO clinical stage; All children and adolescents older than 5 years, and who are living with HIV, should be started on ART if their CD4 count is 350 cells/mm3, irrespective of WHO clinical stage; All children and adolescents living with HIV and who are WHO clinical stages 3 and 4, irrespective of CD4 count, should be started on ART; Children living with HIV with no exposure to maternal or infant non-nucleoside reverse transcriptase inhibitors (NNRTIs), or whose exposure to maternal or infant antiretroviral (ARV) is unknown, should have 2 nucleoside reverse transcriptase inhibitors (NRTIs) + 1 NNRTI in the first-line regimen; For children living with HIV who have been exposed to maternal or infant NNRTIs, the first-line regimen should be 2 NRTIs + 1 protease inhibitor; All Member States should ensure access to paediatric fixed-dose combinations; All HIV-exposed infants should be started on cotrimoxazole preventive therapy (CPT) at 4 6 weeks after birth and continue this treatment until HIV infection has been excluded and the infant is no longer at risk of acquiring HIV through breastfeeding; All children under 2 years of age with confirmed HIV infection should be started on CPT, irrespective of CD4 count or WHO clinical stage; All children between 2 and 5 years of age, who are living with HIV with WHO clinical stage 2, 3 or 4, or with CD4 counts 750 cells/mm3, or %CD4+ 25, should be started on CPT; CPT should be continued up to age of 5 years, at which time the need for CPT should be reassessed; and All children older 5 years of age and adolescents living with HIV with WHO clinical stage 2, 3 or 4, or CD4 <350 cells/mm3, should be started on CPT, according to adult guidelines. Routine follow-up and care for children living with HIV Regular follow up and pre-art care services should be made available to all children and adolescents who are not yet eligible for ART; Monitoring of growth, development and nutrition of children living with HIV should routinely be done on a monthly basis until the age of 18 months, and every 3 months thereafter; A transition plan from child to adult services should be in place in all Member States for adolescents living with HIV; CD4 routine monitoring should be made available and performed as a minimum at the time of HIV diagnosis and every 6 months thereafter; Targeted viral load testing should be in place to be initially used for children and adolescents that are suspected of failing treatment; All children and adolescents living with HIV should have access to services for disclosure, sexual and reproductive health needs, and psychosocial support; A functional patient monitoring system that includes tracking of children and adolescents who are lost to follow-up should be put in place; All terminally ill children and adolescents living with HIV should receive holistic palliative care; and Appropriate pain and symptom control medication should be made available at all levels of health care service delivery. Drug resistance monitoring for HIV [28] Member States should have a system in place to monitor and address HIV drug resistance in children and adolescents who are experiencing treatment failure, and in recently infected populations; Children and adolescents who are failing on a second-line drug regimen should have access to drug-resistance testing. Laboratory services may be provided at the national or supranational level; and

15 Minimum Standards for Child and Adolescent HIV, TB and Malaria 13 Member States should put in place quality tracking systems, including use of early warning indicators to prevent the emergence of HIV drug resistance. HIV and TB co-infection All children and adolescents living with HIV: - Should be actively screened for TB at each visit; - Who are exposed to TB through household contacts, but with no evidence of active disease, should be provided with isoniazid preventive therapy (IPT); - Who are diagnosed with active TB should begin TB treatment immediately, and start ART as soon as tolerated in the first 8 weeks of TB therapy, irrespective of CD4 count; and - Who are receiving ART and who develop TB should start TB treatment immediately, while continuing ART and adjusting ART regimens as recommended for TB co-infection. 7.2 Standards for TB prevention, diagnosis, treatment and care in children and adolescents [29] TB prevention Bacille Calmette Guérin immunisation All children should receive Bacille Calmette-Guérin (BCG) vaccination at birth as part of routine immunisation; Children with symptomatic HIV should not receive BCG vaccination; and Infants born to a mother with smear-positive pulmonary TB should receive BCG immunisation after completing 6 months of IPT or TB treatment. TB infection control TB infection control guidelines should be in place and in operation in all health facilities [30]; All children and adolescents in household contact with a newly diagnosed case of pulmonary TB should be evaluated for TB disease; All children and adolescents in household contact with a newly diagnosed case of multidrug-resistant TB (MDR- TB) should receive appropriate clinical follow up for 2 years; All children and adolescents with prolonged productive cough (> 2 weeks), fever, night sweats, weight loss or failure to thrive should be evaluated for TB; Children and adolescents living with HIV should be screened for TB at each visit, using a clinical algorithm; and Pregnant women should receive antenatal testing for HIV and screening for TB using a clinical algorithm. Isoniazid preventive therapy All children under 5 years of age and all children living with HIV (irrespective of age) without symptoms of active TB, and who have been in close contact with a source case, should be provided with IPT according to WHO guidelines; All infants breastfeeding from a mother with smear-positive pulmonary TB should be provided with IPT according to WHO guidelines; and Neonates born to mothers with pulmonary TB who have received less than 2 months of TB treatment should be evaluated for active TB. Once active TB is excluded, the neonate should receive IPT. TB diagnosis Diagnosis of TB in children and adolescents should be based on clinical evaluation and the following investigations: - Tuberculin skin test using the Mantoux method; - Chest radiography; and - Sputum (in children old enough to produce it) or gastric aspirate for smear microscopy and culture. TB treatment and care TB treatment Directly observed treatment, short course (DOTS) should be provided for the care of children and adolescents with TB disease; Pyridoxine should be made available for all children and adolescents receiving isoniazid; and TB drug resistance monitoring systems should be in place.

16 14 Minimum Standards for Child and Adolescent HIV, TB and Malaria Routine follow-up and care for children with TB Children and adolescents: - Should be followed monthly during intensive phase of treatment and bi-monthly during continuation phase as a minimum; - With suspected treatment failure should be referred for further assessment, including evaluation for MDR- TB; and - Should be monitored for growth, development and nutrition status during treatment of TB. All children and adolescents diagnosed with TB (suspected, probable or confirmed) should be tested for HIV; All children and adolescents who are terminally ill should receive holistic palliative care; and Appropriate pain and symptom control medication should be made available at all levels of health care service delivery. 7.3 Standards for malaria prevention, diagnosis, treatment and care in children and adolescents [20] Malaria prevention Malaria-free countries should prevent the reintroduction of malaria by strengthening mechanisms to manage imported malaria cases; and Screening of malaria in other children, adolescents and adults (contact tracing) in the same household should be performed in malaria pre-elimination countries. Insecticide-treated nets In Member States with malaria control programmes children and pregnant women should be priority recipients of long-lasting insecticide nets (LLINs), although the whole population should be protected; LLINs should be provided free of charge in malaria-endemic areas to pregnant women and to children younger than 5 years through antenatal clinics and maternal, neonatal and child health clinics. Such provision should be accompanied by adequate counselling on the importance of regular and correct use of the LLINs; and Universal coverage of ITNs should be maintained in malaria-endemic countries. Indoor-residual spraying High quality annual indoor-residual spraying (IRS) should be provided and maintained; Adequate monitoring, quality assurance and quality control of IRS programmes should be ensured; and Regular surveillance of mosquito resistance should be introduced. Malaria diagnosis Every suspected malaria case, including children, should be confirmed by microscopy or RDT prior to treatment; In countries with malaria control programmes, if parasitological confirmation is not available, clinical diagnosis of malaria in children should be performed according to the latest WHO guidelines; Microscopy should be the preferred option in cases of suspected severe malaria or non Plasmodium falciparum malaria; Scale-up of malaria diagnostic testing should be integrated with efforts to improve the management of other febrile illnesses; and All diagnostic tools should be quality-assured across all levels of the health system. Malaria treatment and care Anti-malaria treatment Anti-malaria treatment solely on the basis of clinical suspicion should only be considered in cases where parasitological diagnosis is not accessible and in countries with malaria control programmes, but not in countries with malaria elimination programmes; The results of parasitological diagnosis should be available promptly (within less than two hours) after a patient presents. In the absence or in the case of delay of parasitological diagnosis, patients with suspected severe malaria, and other high-risk groups, should be treated immediately on clinical grounds; The first-line treatment for children with uncomplicated malaria should be Artemisinin-based combination therapy (ACT) in fixed-dose combinations, according to the latest WHO guidelines; The first-line treatment for children with severe P. falciparum malaria should be intravenous/intramuscular artesunate (given within 24 hours), followed by a full course of oral ACT as soon as the patient recovers, as recommended in the latest WHO guidelines;

17 Minimum Standards for Child and Adolescent HIV, TB and Malaria 15 Use of quinine as first-line treatment for children with severe P. falciparum malaria should be reserved for cases where intravenous artesunates are contraindicated or unavailable; Strong referral systems for children with severe malaria to the highest level of care should be in place; Pre-referral treatment with intramuscular artesunate, artemether or quinine or rectal artesunate should be made available, according to the latest national guidelines; Where referral is not possible, intramuscular/rectal treatment should be continued until the patient can tolerate oral medication, at which point a complete course of an effective ACT should be administered; Regular monitoring of parasite resistance every two/three years should be undertaken to ensure the use of efficacious medicines; Malaria prevention and treatment in malaria-affected areas should be prioritised for HIV-infected children; and Malaria diagnosis and treatment at community level should be implemented and expanded in countries, using integrated community case management and home-based management of malaria approaches. Follow-up and care for children and adolescents with malaria Children and adolescents treated for uncomplicated malaria should be followed up to ensure adherence to treatment and for any additional support that may be required; Children and adolescents with severe malaria should be immediately hospitalised for intensive management; and Children and adolescents treated for severe malaria should be followed for proper management of sequelae after treatment. 7.4 Cross-cutting standards on care and support for children and adolescents Nutritional assessment, counselling and support At each visit, all children and adolescents should be monitored for growth, development and nutrition; Nutritional assessment, counselling and support should be provided to caregivers, children and adolescents to enhance treatment effectiveness and adherence, retention in care and quality of life in children and adolescents; Children and adolescents who have severe acute malnutrition should receive therapeutic feeding, while children and adolescents with moderate acute malnutrition should receive supplementary feeding; and Member States should adopt community management of acute malnutrition as a strategy for implementation. Social protection HIV, TB and malaria services for children and adolescents should be provided free of charge; and Member States should put in place social protection mechanisms to enable orphans and other vulnerable children, and youth to have access to services. Psychosocial support Age-appropriate psychosocial support (PSS) should be provided to children and adolescents to ensure adherence to HIV and TB treatment and care, and to encourage positive living for those living with HIV; Child and adolescent-friendly PSS should be provided to all acute and chronically ill children and adolescents; Adolescent-friendly PSS should be provided to adolescent parents; and Caregivers should receive counselling, care and support to avoid burnout and maximise adherence to ART, TB and malaria treatment for the affected children and adolescents. Child and adolescent protection All children and adolescents presenting at health facilities or health care providers without birth registration should be treated and immediately referred for birth certification; Children and adolescents crossing borders (including migrants, refugees and internally displaced populations) should be treated free of cost, irrespective of birth registration, and should then be referred for birth registration; and Unaccompanied children and adolescents, and victims of trafficking presenting at health facilities or health care providers should be treated free of cost and referred immediately for social support or home affairs services. Child- and adolescent-friendly services All health facilities should provide integrated, gender-sensitive, child and adolescent-friendly health services.

18 16 Minimum Standards for Child and Adolescent HIV, TB and Malaria Community home-based care Community home-based care (CHBC) programmes should include specific provisions for children and adolescents: - Living with HIV, HIV/TB co-infection, TB or malaria; - Living in households where there is a person living with HIV, HIV/TB, TB or malaria; and - Who are caregivers, heads of households and other vulnerable children. Caregivers from school environments, communities, faith-based organisations and health facilities should receive capacity strengthening on best practices that target the needs of children and adolescents living with HIV; All terminally ill children and adolescents, and their caregivers should receive holistic palliative care including through CHBC; and Appropriate pain and symptom control medication should be made available at all levels of health care service delivery. Advocacy, communication and social mobilisation Member States should develop appropriate information, education and communication material that address the diseases in children and that are child- and adolescent-oriented; Member States should develop capacity in communities among caregivers and older children and adolescents to apply skills in prevention, treatment, care and support (such as adherence to DOTS and the correct use of ITNs); and Member States should ensure the establishment of linkages between communities, child- and youth-led organisations and health facilities for effective community, child and adolescent participation in service delivery. Care and treatment across Member States borders Formal agreements, mechanisms and tools should be established for referral and transfer of children and adolescents living with HIV, TB and malaria across borders within the SADC region Standards on health systems strengthening and integration Health systems strengthening [31] Member States should have: Effective, safe and quality HIV, TB and malaria health services for children and adolescents down to the community level, and those services should be fully integrated into the PHC system; Policies and strategies in place for recruiting, distributing and retaining appropriate and adequate human resources for health; Pre-service and in-service training in child and adolescent HIV, TB and malaria; A national framework and policy for task shifting or task sharing in HIV, TB and malaria prevention, diagnosis, treatment and care for children and adolescents; A comprehensive training programme that includes supervision and support to health care workers who perform task shifting or task sharing activities for children and adolescents; Health information systems that collect, generate, analyse and use reliable information on child and adolescent health determinants, status and health system performance; Equitable access to effective, safe and quality medical products and technologies for children and adolescents; Funds allocated for child and adolescent health to ensure that they have universal access to health, and those funds should be raised through a strong health financing system; and Leadership and governance to strengthen health systems for comprehensive child and adolescent care that include oversight, partnership building, regulation and accountability. Supply chain management The procurement and supply chain management system should ensure regular provision of drugs and commodities for child and adolescent HIV, TB and malaria treatment, prevention and control; Member States should explore the use of mobile health technology towards facilitating procurement and minimising stock-outs; and Policies that prioritise regulatory approval of new and generic medicines and diagnostics, and that expedite their marketing should be developed.